The situation of water, sanitation and hygiene in schools - in the pan-European region

 
The situation of water, sanitation and hygiene in schools - in the pan-European region
The situation of water,
sanitation and hygiene
      in schools
     in the pan-European region

   By Valentina Grossi, Emanuel Klimschak, Andrea Rechenburg,
              Enkhtsetseg Shinee and Oliver Schmoll
Abstract
     Adequate access to water, hygiene and sanitation (WASH) is every human’s and child’s right. Ensuring WASH accessibility
     in schools is encompassed in the 2030 Agenda for Sustainable Development and is a priority area under the Protocol on
     Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International
     Lakes. This publication summarizes the status of WASH in schools in the pan-European region. Available evidence
     was retrieved from scientific literature, national and international surveys and a desk review of case studies. The data
     show general progress in WASH policies and targets, but a concurrent lack of translation of this progress into efficient
     improvement of WASH in schools. Gaps and challenges are found as a result of non-comprehensive standards, inefficient
     coordination and inadequate surveillance and monitoring indicators. Further, neglected disparities and inequalities are
     observed through the region. WASH conditions do not reflect policies’ aspirations and are not adequate to pupils’ needs,
     affecting their health, well-being and performance at school. The main challenges across the region are related in particular
     to inadequate cleanliness and provision of consumables, as well as maintenance of sanitation facilities and accessibility to
     safe drinking-water. Policy-making needs to be supported by evidence-based information, especially on neglected topics
     such as menstrual hygiene management.

                                                            Keywords
                                                          CHILD HEALTH
                                                             EUROPE
                                                            HYGIENE
                                                           SANITATION
                                                            SCHOOLS
                                                          WATER SUPPLY

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ii
The situation of water,
sanitation and hygiene
      in schools
     in the pan-European region

   By Valentina Grossi, Emanuel Klimschak, Andrea Rechenburg,
              Enkhtsetseg Shinee and Oliver Schmoll
Contents

     List of figures, tables and boxes............................................................................................... iii

     Acknowledgments..................................................................................................................... iv

     Abbreviations............................................................................................................................. vi

     Executive summary.................................................................................................................. vii

     1      Introduction.........................................................................................................................1

     2      Methods..............................................................................................................................5

     3      Policy framework on WASH in schools in the pan-European region..................................9
     3.1. National policies and standards on WASH in schools........................................................10
     3.2. Targets for WASH in schools.............................................................................................15
     3.3. Implementation of policies and targets...............................................................................17
     3.4. Surveillance.......................................................................................................................20

     4      WASH conditions in schools: results from national surveys.............................................25
     4.1. Overview of national surveys..............................................................................................26
     4.2. Highlights..........................................................................................................................35

     5      Scientific evidence on WASH in schools..........................................................................39
     5.1. Overview of the reviewed literature.....................................................................................40
     5.2. Highlights..........................................................................................................................52

     6      Conclusions and recommendations.................................................................................57
     6.1. Conclusions........................................................................................................................58
     6.2. Recommendations.............................................................................................................62

     References...............................................................................................................................65

ii
List of figures, tables and boxes

Figures
Fig. 1. Flowchart of the selection process undertaken in the literature review............................7
Fig. 2. Summary of challenges and issues concerning WASH in schools................................35

Tables
Table 1. Search terms and number of results of the literature review.........................................7
Table 2. Requirements for WASH in schools addressed by national policies............................11
Table 3. Examples of additional parameters specified in the standards
         for WASH in primary and secondary schools.............................................................12
Table 4. Examples of fittings to pupils ratios specified in the standards
         for primary and secondary schools............................................................................12
Table 5. Examples of national standards.................................................................................13
Table 6. Examples of WASH in schools targets set under the Protocol....................................16
Table 7. Examples of WASH in schools coverage targets set..................................................17
Table 8. Stages of development and implementation of national policies
         and plans for WASH in schools..................................................................................18
Table 9. Examples of programmes and/or planned activities on WASH in schools..................19
Table 10. Examples of requirements for frequency of WASH surveillance
          specified in national legislation.................................................................................20
Table 11. National coverage estimates for WASH in primary schools......................................22
Table 12. Countries where a national survey/assessment was carried out...............................26
Table 13. Summary of national surveys of WASH in schools for the
          pan-European region..............................................................................................27
Table 14. Summary of scope and outcomes of the reviewed literature....................................40

Boxes
Box 1. New guidelines for WASH in schools in Georgia..........................................................14
Box 2. National coordinating mechanism for WASH in schools...............................................15
Box 3. National WASH in schools coverage estimates............................................................22
Box 4. Additional information on WASH-related issues in the pan-European region................34

                                                                                                                                 iii
Acknowledgements

     The WHO Regional Office for Europe and the United Nations Economic Commission for Europe
     wish to express their appreciation to those whose efforts made the production of this publication
     possible. Special thanks are due to the German Federal Ministry for the Environment, Nature
     Conservation, Building and Nuclear Safety; the Hungarian Office of the Chief Medical Officer;
     and the Hungarian National Institute of Public Health, which provided financial support for the
     development of the publication and for meetings.
     The publication was developed under the guidance of the expert group on water, sanitation and
     hygiene in schools, established under the Protocol on Water and Health to the 1992 Convention
     on the Protection and Use of Transboundary Watercourses and International Lakes, which met in
     Budapest, Hungary (April 2015) and Bonn, Germany (October 2015). The Protocol’s Working Group
     on Water and Health also reviewed and endorsed the publication. Oliver Schmoll and Enkhtsetseg
     Shinee coordinated the development of this work for the WHO Regional Office for Europe.

     The authors are:
     • Valentina Grossi, Institute for Hygiene and Public Health, University of Bonn, Germany;
     • Emanuel Klimschak, Institute for Hygiene and Public Health, University of Bonn, Germany;
     • Andrea Rechenburg, Institute for Hygiene and Public Health, University of Bonn, Germany;
     • Enkhtsetseg Shinee, Water and Sanitation Programme, WHO European Centre for Environment
       and Health, WHO Regional Office for Europe, Bonn, Germany;
     • Oliver Schmoll, Water and Sanitation Programme, WHO European Centre for Environment and
       Health, WHO Regional Office for Europe, Bonn, Germany.

iv
Acknowledgements

Thanks are due to the following international experts, who contributed valuable conceptual input,
data and country-specific information on water, sanitation and hygiene in schools, as well as peer
review.

• Corina Andronic, Swiss Water and Sanitation (ApaSan) Project, Republic of Moldova;
• Andrew Dailly, School Infrastructure Unit, Learning Directorate, Scottish Government, United
  Kingdom;
• Nana Gabriadze, Environmental Health Division, National Centre for Disease Control and Public
  Health, Georgia;
• Mihail Kocubovski, Institute of Public Health, the former Yugoslav Republic of Macedonia;
• Oxana Levchenko, Federal Service for Supervision of Consumer Rights Protection and Human
  Well-Being, Russian Federation;
• Peter van Maanen, independent WASH consultant, France;
• Orkhan Mustafayev, Ministry of Education, Azerbaijan;
• Nana Pruidze, United Nations Children’s Fund, Georgia;
• Ion Salaru, National Centre of Public Health, Republic of Moldova;
• Margriet Samwel, Women in Europe for a Common Future, Netherlands;
• Oxana Sinitsyna, AN Sysin Research Institute of Human Ecology and Environmental Health,
  Russian Federation;
• Esenbek Turusbekov, United Nations Children’s Fund, Kyrgyzstan;
• Márta Vargha, Department of Water Hygiene, National Public Health Centre, Hungary.

                                                                                                        v
Abbreviations

     EECCA		   eastern Europe, the Caucasus and central Asia

     GLAAS		   UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water

     HWF		     handwashing facility

     JMP		     WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation

     MHM		     menstrual hygiene management

     NGO		     nongovernmental organization

     RPG		     Regional Priority Goal

     SDG		     Sustainable Development Goal

     UNICEF    United Nations Children’s Fund

     WASH		    water, sanitation and hygiene

vi
Executive summary

Scope and objective
This publication summarizes the status of water, sanitation and hygiene (WASH) in schools in the
pan-European region and provides a comprehensive insight into the progress made and challenges
concerning WASH in schools. It was mandated under the programme of work for 2014–2016 of
the Protocol on Water and Health and aspires to serve as a sound evidence basis for informed
policy action on WASH in schools.

Methods
Available evidence on the condition of WASH in schools was retrieved from scientific literature and
national surveys. Relevant information about policies on WASH in schools and their implementation,
as well as national coverage, was collected from international surveys and a desk review of case
studies. These included the 2014 UN-Water Global Analysis and Assessment of Sanitation and
Drinking-Water report, the 2015 WHO report School environment: policies and current status and
the 2015 United Nations Children’s Fund report Advancing WASH in schools monitoring.

Main findings

Policies and regulations on WASH in schools

Most countries have standards in place, but these are diverse and often neglect critical
WASH aspects.
National standards and regulations are commonly in place. Countries choose and regulate the
essential requirements for ensuring adequate WASH in schools differently, however. Important
aspects are not always addressed or regulated in line with international standards on, for example,
pupil–toilet ratios and similar.

The legal framework is complex and lacks efficient coordination.
The legal framework is complex and spreads responsibilities among numerous institutions
without a clear leading actor, thus compromising accountability, coordination and compliance.
Communication and formally established coordination systems between the institutions involved
are not always efficient, sometimes lacking a clear key actor with overall responsibility. Leadership
on WASH in schools in the education sector is often weak, as WASH in schools is not considered
an education intervention.

Policies and targets are set, confirming countries’ commitment and reflecting priorities,
but full implementation and improvement of WASH in schools is impeded.
Policies and targets on WASH in schools are mostly in place and national targets or programmes
for improving WASH in schools have been approved in many countries. Enforcement mechanisms
are not always well established, however. Policies and plans are often not fully implemented and
financed. Coverage and the WASH aspects considered may vary, with hygiene less prioritized than
water and sanitation. Successful implementation is observed associated with active participation
of the school community, which fosters improvement in cleanliness and maintenance, promoting
healthy behaviours and disease prevention.
                                                                                                        vii
Policy-making will not be successful unless critical gaps in surveillance are addressed
       and monitoring indicators improved.
       Data from many countries indicate that surveillance systems and specific surveillance requirements
       for WASH in schools are often in place. Nevertheless, actual monitoring is not always regular,
       frequently has limited coverage and often does not actively engage either schools or education
       authorities. Indicators may be inadequate and/or heterogeneous, affecting data accuracy and
       comparability, and monitoring is not seen as a tool for informing and implementing policies and
       improvement interventions. Existing legislation and standards cannot be translated successfully
       into effective improvement action planning unless the problems and gaps hindering their application
       are known.

       WASH conditions in schools

       The reality of WASH in schools does not reflect the aspirations of standards in place and
       is not adequate to pupils’ needs.
       WASH in schools presents many challenges, regardless of the economic status of the country
       and the existence of policies and regulations. The most frequently reported issues relate to
       inappropriate planning; problems with physical infrastructure; a lack of consumables; poor cleaning
       and maintenance; and inadequate operation of water supply, sanitation and hygiene services. Pupil
       perception surveys reveal frequent dissatisfaction due to insufficient cleaning and maintenance,
       which is not always acknowledged by school management and staff, hindering healthy behaviours
       and promoting antisocial behaviours, such as vandalism.
       • Access to water for drinking and handwashing in schools is often not ensured.
          Water may be absent, intermittent, unsafe and/or hard to access, far away or not allowed in
          class. Insufficient numbers or inadequate handwashing facilities and overly cold temperatures
          also hinder handwashing practices.
       • Hygiene management and practice are not always adequate in schools.
          Toilets are frequently reported to be dirty, overcrowded and smelly; soap, toilet paper, drying
          devices and disposal bins to be insufficient. As a consequence, toilet avoidance is common
          among pupils and a lack of adequate hygiene education means that the practice of healthy
          behaviours is not promoted.
       • Sanitation is not always adequately provided and maintained or accessible.
          Sanitation facilities may be absent or inadequate to pupil numbers and needs. Use of sanitation
          facilities is hindered by insufficient maintenance and cleanliness, poor building materials, lack of
          privacy, cold temperatures and poor illumination.
       • Disparities and inequalities permeate WASH accessibility in schools.
          Children with disabilities do not have equal access to WASH facilities in schools. Girls’ needs,
          especially during menstruation, are often not considered. Members of minority groups in rural
          areas or specific regions do not have equal access to WASH facilities in schools and are
          neglected by policies and funding programmes.

viii
Executive summary

Scientific evidence on impacts of WASH in schools on pupils’ health and
well-being

Inadequate WASH affects children’s health, well-being and cognitive performance.
The studies undertaken, although limited in number, indicate a clear association between children’s
health and WASH conditions in schools. A significant number of pupils avoid using WASH facilities,
with consequences on health, well-being and cognitive performance. Inadequate WASH in schools
may result in dehydration, urinary infections and constipation and, in some countries, parasitic
infections. The evidence shows that toilet avoidance is fostered not only by insufficient and
inadequate facilities but also by a lack of awareness among both teachers and children concerning
the importance of WASH and the consequent school policies for drinking and toilet visits. Available
studies also reported a beneficial effect of hygiene interventions, with a significant reduction of
absenteeism due to infections during and/or after the intervention.

Policy-making needs to be supported by scientific research, especially on neglected
topics.
The scientific research and monitoring data from the pan-European region are limited, especially
with respect to middle-income countries. Important WASH-related topics like menstrual hygiene
management, hygiene education and WASH-related health assessments still lack prioritization. As
a consequence, the data available on the association between WASH in schools and related health
problems or learning outcomes, as well as on the effectiveness of interventions to support informed
policy action, are very limited.

                                                                                                         ix
Introduction 1

             1
Access to water, sanitation and hygiene (WASH) is essential for healthy development and growth
    of children all around the world. Adequate access to WASH is every child’s right, as stated in the
    Convention on the Rights of the Child (United Nations, 1989).
    The recently approved 2030 Agenda for Sustainable Development (United Nations, 2015) also
    encompasses WASH in schools under the Sustainable Development Goals (SDGs) for health and
    well-being (SDG 3), education (SDG 4) and water and sanitation (SDG 6). The new Agenda explicitly
    addresses WASH in institutional settings like schools, and calls on countries to:
    • reduce the burden of WASH-related diseases (targets 3.3 and 3.9);
    • achieve universal and equitable access both to safe and affordable drinking-water (target 6.1)
      and to adequate and equitable sanitation and hygiene (target 6.2);
    • improve the learning environment in schools (target 4.a) for all by 2030.
    The Parma Declaration on Environment and Health, adopted at the Fifth Ministerial Conference on
    Environment and Health (WHO Regional Office for Europe, 2010), addresses health risks to children
    posed by poor environmental, working and living conditions, including risks posed by the lack of
    adequate WASH. By signing the Parma Declaration, Member States in the WHO European Region
    entered into a Commitment to Act on Regional Priority Goal 1 (RPG1), which “strive[s] to provide
    each child with access to safe water and sanitation in homes, child care centres, kindergartens,
    schools, health care institutions and public recreational water settings by 2020, and to revitalize
    hygiene practices”.
    The Protocol on Water and Health to the 1992 Convention on the Protection and Use of
    Transboundary Watercourses and International Lakes, adopted at the Third Ministerial Conference
    on Environment and Health (UNECE & WHO Regional Office for Europe, 2006), is the key regional
    policy instrument supporting implementation of RPG 1 at the national level. The Protocol’s objective
    is to prevent, control and reduce water-related disease through sustainable water management.
    The third session of the Meeting of the Parties to the Protocol in 2013 in Oslo, Norway, adopted
    the 2014–2016 programme of work, which for the first time included a priority area concerned
    with improving and strengthening WASH in schools. Thanks to the work done under the Protocol,
                                                                                                       1
    WASH in schools has received increased attention in many countries in the pan-European region.
    To support implementation of the 2014–2016 programme of work, the WHO Regional Office for
    Europe organized a meeting on advancing WASH in schools in Bonn, Germany, in September
    2014. This brought together more than 50 participants from health and educational departments of
    24 Member States, as well as from the United Nations Children’s Fund (UNICEF), leading academic
    institutions, development aid agencies and nongovernmental and youth organizations. The meeting
    recommended, inter alia, preparation of a landscape report summarizing the evidence on WASH
    in schools through a literature review, appraisal of available survey information and identification of
    best practice case studies in school regulation, surveillance and management.

    1
        This publication uses the term “pan-European region” to refer to the Member States in the WHO European Region and
        Liechtenstein. The WHO European Region comprises 53 countries: Albania, Andorra, Armenia, Austria, Azerbaijan,
        Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France,
        Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania,
        Luxembourg, Malta, Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania,
        Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, the former
        Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom and Uzbekistan.
2
Introduction_1

The aim of this publication is thus to provide an insight into the current state of WASH in schools in
the pan-European region. Based on a systematic review of available scientific literature, international
and national surveys, this report summarizes:
• policies and national regulations, including progress made in establishing and implementing
  national requirements for WASH in schools, and related challenges;
• available data about access to and functionality of WASH facilities in school settings;
• issues and challenges concerning WASH in schools and its effects on health, well-being and
  learning and the school environment.
This report complements the publication Prioritizing pupils’ education, health and well-being (van
Maanen et al., 2016) with evidence and examples, in support of Member States’ and WHO’s
deliberations on advancing the agenda for universal access to WASH in schools. It aims to inform
future priority activities under the Protocol’s programme of work for 2017–2019 and to support
the Parties to the Protocol in informed target-setting and the development of efficient and focused
strategies. The findings of the report will also be useful for other stakeholders committed to and
working on improving WASH in schools as a fundamental objective to protect children’s health and
to ensure basic human rights.

                                                                                                            3
Methods 2

        5
This publication consists of a systematic review of the data concerning WASH in schools in the
    pan-European region. In order to present a comprehensive landscape report, “WASH in schools”
    is defined as WASH in all types of education premises and childcare settings.
    An overview of the current situation regarding policies and standards for WASH in schools and the
    associated political achievements in the region is given in Chapter 3. This is based on analysis of
    results reported by the following international surveys:
    • the 2014 UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS)
      report, which provides analyses of the state of the enabling environment, including governance,
      monitoring, human resources and financing directed to the WASH sector and the factors
      influencing progress on the delivery of services, and the raw data used to produce the report
      (WHO, 2014a; 2014b); this publication considers the information related to the 12 countries in
      the pan-European region that participated in the 2013–2014 GLAAS reporting cycle;
    • the 2014 policy survey on the school environment conducted by the WHO Regional Office for
      Europe (2015), which assesses national and subnational progress in the implementation of the
      commitments made in the Parma Declaration, including RPG1 on WASH;
    • the survey on WASH in schools coverage estimates published by UNICEF (2015), including
      national estimates for WASH in primary schools in 19 countries in the pan-European region;
      this promotes and supports improved monitoring of WASH in schools, focusing on coverage
      (gathered from 149 countries between 2008 and 2013) and monitoring indicators.
    The chapter provides further analysis concerning national standards and policies in place among
    countries in the pan-European region. Information was retrieved from online governmental
    databases, journals and relevant surveys (UNICEF Regional Office for CEE/CIS, 2010; UNICEF
    Georgia, 2012; ONS, 2013); further information was reported by personal communication from
    country representatives.
    Chapter 3 also compiles and evaluates targets on WASH in schools set by the Parties to the Protocol
    under the provisions of Article 6, as well as the summary reports submitted for the third session of
    the Meeting of the Parties according to Article 7 (UNECE, 2016). Complementary information on
    national WASH in schools programmes and plans was collected through country briefs or personal
    communications from country representatives who participated in the WHO meeting on advancing
    WASH in schools (Bonn, Germany, September 2014) and the first expert group meeting on WASH
    in schools (Budapest, Hungary, April 2015).
    Chapter 4 provides an in-depth analysis of the conditions of WASH in schools in countries in
    the pan-European region, based on information available from national surveys undertaken by
    state institutions, nongovernmental organizations (NGOs) and international agencies. The surveys
    reviewed were retrieved either from the public domain or via personal communication. Most were
    in English; surveys in French, German, Italian and Russian were also analysed.
    An Internet search was also conducted for each country in the region using Google and Bing
    search engines to compile further information on national policies, as well as case studies on
    school regulation, surveillance and management. Complementary information provided at the two
    WHO meetings of September 2014 and April 2015 was taken into account, especially for countries
    whose data were not otherwise available.
    Chapter 5 presents the findings of a systematic review of the scientific literature, adapted from
    Jasper et al. (2012), to assess the state of WASH in schools in the pan-European region in terms
    of prevailing inadequacies and observed effects of impaired or improved access to WASH on
    pupils’ health. Peer-reviewed literature available in the public domain and retrievable from the
    scientific databases PubMed and ScienceDirect was screened. Articles addressing topics relevant
    to WASH in schools were selected – namely, those related to handwashing, sanitation and toilet
    facilities, hygiene education, drinking-water provision, menstrual hygiene and health assessments.
6
Methods_2

Studies without a school-based component were excluded. Publications that referred to schools,
nurseries, day care facilities or kindergartens were considered. Only articles published between
2000 and 2014 in English or German were included in the review.
The primary research was based on general search terms (Table 1), covering all potential associated
terms (such as “water well”, “water waste” and so on) and health outcomes. This identified 25 482
publications whose title or keywords incorporated a single search term or a combination of terms.

Table 1. Search terms and number of results of the literature review

Search terms                                                          PubMed                   ScienceDirect

                                                             By title/abstract      By title/abstract/keywords
      a
school AND water OR sanitation                                          8 014                              827
      a
school AND hygiene                                                       419                               599

school health policies AND water OR sanitation                          7 197                               21

school health policies AND hygiene                                          0                               15
      a          a
school AND toilet                                                        757                                59

school absenteeism AND water OR sanitation                              6 771                                 2

school toilets                                                             19                               47
        a          a
handwash AND school                                                         0                               19
                               a
hand washing AND school                                                  379                                23
                              a
handwashing AND school                                                   296                                18

Total search results                                                   23 852                            1 630

a
    Including additional long-tail keywords that came up during the research and were considered relevant (e.g.
    schoolchildren, preschool, school facilities and so on).

A screening was then conducted of all article abstracts. Global reviews were not further considered
but were screened for relevant literature. During a secondary screening, the articles were hand-
searched for relevant content and countries to exclude those not related to WASH in schools but
primarily covering aspects such as food hygiene, studies located outside the pan-European region
and duplicates. Where articles used identical data sets, only one was kept. At the end, 35 studies
met all the inclusion criteria (Fig. 1).

Fig. 1. Flowchart of the selection process undertaken in the literature review

    Primary research                Screening                            Secondary screening
    Screening by search             Abstract screening by inclusion      Hand screening for content
    terms in PubMed and             criteria:                            and country; hand screening
    ScienceDirect databases                                              of review bibliography
                                    English/German abstract;
    25 482 articles                 published after 2000;                35 articles
                                    comprising a single search term
                                    or a combination of terms

                                                                                                                  7
The scientific databases used for the literature search cover 5605 (PubMed) and 3608 (ScienceDirect)
    journals in different languages and provide at a minimum an English title, keywords and abstract.
    Articles that were only available in a language other than English or German and were not referenced
    by the two large literature search databases were thus excluded. It is therefore acknowledged that
    the search method may have excluded relevant scientific literature, especially because WASH in
    schools literature may have been published in various languages in national journals. Nevertheless,
    it is assumed that a substantial part of the scientific research of high quality will be published
    in international journals to increase scientific visibility and recognition. In addition, experts and
    country representatives who participated in the WHO meetings were asked to provide possible
    missing literature from national sources. Seven additional articles were added after the initial review,
    including five peer-reviewed articles in Russian.

8
Policy framework 3
on WASH in schools
in the pan-European
               region

                     9
This chapter outlines the current situation concerning policies, plans and targets for WASH in
     schools adopted in countries in the pan-European region. It summarizes the findings of relevant
     international surveys – in particular, the 2014 GLAAS survey (WHO, 2014a), the 2014 policy survey
     on the school environment conducted by the WHO Regional Office for Europe (2015) and the
     UNICEF survey on WASH in schools coverage estimates (2015). It also presents an overview of
     national targets that countries set under the Protocol on Water and Health to provide closer insight
     in the areas and details chosen in different countries of the region. Finally, the chapter provides
     examples of national policies and legislation from selected countries, including information on
     adopted mechanisms for sector coordination and surveillance systems in place.

     3.1. National policies and standards on WASH in schools

     Policies and standards are in place, but they are not always comprehensive and often
     neglect critical WASH aspects.

     According to the information obtained and analysed from 42 countries in the pan-European region,
                                                                                 2
     at least 40 report having policies in place that address WASH in schools. Most of these have
     legally binding requirements, while some have non-statutory guidelines – either in place of or
     complementing/extending the legal requirements.
     Table 2 provides an overview of technical areas commonly covered by national policies in the
     region, aimed at ensuring children’s access to adequate sanitation and hygiene in schools. Different
     countries consider it essential to regulate different parameters. Positive progress is nonetheless
     observed: in the majority of countries the policies encompass requirements related to key aspects
     (such as privacy, adequate illumination and temperature) and specify maximum numbers of pupils
     per toilet. Further, at least eight countries introduced new policies after the Parma Declaration
     (WHO Regional Office for Europe, 2010).
     Table 3 gives examples of additional standards included in the legislation evaluated from a sample
     of seven countries. These data show the extent and detail of national requirements for WASH in
     schools, covering other important aspects like the proximity of handwashing facilities (HWFs) to
     the toilets or the characteristics of the building materials (such as whether they are easy to clean),
     which are in line with WHO recommendations (Adams et al., 2009), among others.
     Although many countries have policies, analysis of their scope reveals that the main requirements
     are not always in place in accordance with WHO recommendations (Adams et al., 2009). This
     is especially the case regarding the number of pupils per toilet, for which the recommendations
     suggest a ratio of 1:25 toilets to female pupils and 1:50 toilets and urinals to male pupils. This
     limitation might promote overcrowding of WASH facilities and affect hygiene conditions in schools.
     Table 4 provides selected examples of ratios of toilets to pupils retrieved from a desk review of
     related legislation in five countries in the region. It also shows examples of ratios of HWFs to
     pupils, which are not specified in WHO recommendations but are included in the WASH in schools
     standards in 20 countries (see Table 2).

     2
         The countries with policies in place include the 34 that participated in the WHO school policy survey (WHO Regional
         Office for Europe, 2015) and six additional countries, for which information was retrieved from briefs by country
         representatives at the WHO meeting on advancing WASH in schools in Bonn, Germany, in September 2014 or via
         desk reviews: France, Kyrgyzstan, Republic of Moldova, Russian Federation, Ukraine and Uzbekistan.

10
Policy framework on WASH in schools in the pan-European region_3

Table 2. Requirements for WASH in schools addressed by national policies

Requirement                                                                                              Countries

Policy specifying minimum parameters                                                                  34/34 (100%)

   Maximum number of pupils per toilet place                                                           23/34 (68%)

   Maximum number of pupils per handwash basin                                                         20/34 (59%)

   Adequate light in toilets and washrooms                                                             26/34 (76%)

   Comfortable temperature in toilets and washrooms                                                    26/34 (76%)

   Privacy standards for toilet cabins                                                                 25/34 (74%)

   Accessibility for children with disabilities                                                        22/34 (65%)

Policy specifying operation and maintenance                                                            28/34 (82%)

   Provision of adequate amount of toilet paper                                                        17/34 (50%)

   Provision of soap in handwashing facilities                                                         20/34 (59%)

   Provision of adequate amount of water for handwashing                                               23/34 (68%)

   Provision of towels/driers                                                                          21/34 (62%)

   Minimum cleaning requirements for sanitation facilities                                             23/34 (68%)

   Regular inspection and maintenance of sanitation facilities                                         17/34 (50%)

Policy on hygiene education                                                                            28/34 (82%)

   Hygiene education required to be part of school curriculum                                          19/34 (56%)

   Minimum educational requirements specified                                                          16/34 (47%)

   Hygiene education addressing gender-specific aspects                                                11/34 (32%)

Officer responsible for compliance                                                                     23/34 (68%)

Regular surveillance                                                                                   29/34 (85%)

Minimum requirements for inspections                                                                   15/34 (44%)

   Follow-up inspections required if deficiencies found                                                26/34 (76%)

New policies introduced after Parma Declaration                                                          8/34 (24%)

Note: Reporting countries are Albania, Andorra, Armenia, Austria, Belarus, Belgium, Bosnia and Herzegovina, Croatia,
      Czechia, Denmark, Estonia, Finland, Georgia, Germany, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Malta,
      Montenegro, Norway, Poland, Portugal, Serbia, Slovakia, Slovenia, Spain, Sweden, Tajikistan, the former Yugoslav
      Republic of Macedonia, Turkey and the United Kingdom.
Source: WHO Regional Office for Europe (2015).

                                                                                                                         11
Table 3. Examples of additional parameters specified in the standards for WASH in primary and
              secondary schools

     Parameter                            United Kingdom          France      Germany         Hungary      Italy      Russian
                                                                                                                     Federation
                                         England      Wales

     HWFs close to toilets                  ✔           ✔            ✔            ✔             ✔            •               –

     Provision of hot water                 ✔           ✔a            •           •             ✔           ✔                ✔
     Characteristics of building
     materials (e.g. easy to                 •          ✔a           ✔            ✔              •           •               ✔
     clean)

     Accessibility (one facility
     per floor)
                                             •           •            •           ✔             ✔           ✔b               ✔

     Alternatives for areas
     with no centralized water               •           •            •           •              •           •               ✔
     supply or sewage system

     Key: ✔ specified in the legislation analysed; – information not retrievable; • not specified in the legislation analysed.
     a
         Regulated in non-statutory guidelines.
     b
         Regulated only concerning washrooms for disabled people.
     Sources: Department for Education (2012a; 2012b); Department for Education & Welsh Office (1999); Federation Council
              (2011); Health Officer of the Russian Federation (2008; 2010); Hungarian Standards Institution (2012); Lein
              (2013); Ministry for Public Works (1968); Ministry for Public Works & Ministry for Public Education (1975); Ministry
              of Labour (2008); Ministry of Labour, Social Relations and Solidarity (2015); Ministry of Public Education, Youth
              and Sport (1989); Welsh Government (2012).

     Table 4. Examples of fittings to pupils ratios specified in the standards for primary and
              secondary schools

     Country                                  Toilets to pupils ratio      Urinals to pupils ratio HWFs to pupils ratio
                                                   Boys | Girls
     France                                         1:20 | 1:10                       1:20                         1:3
                                                       a      a
     Germany                                       1:50 | 1:25                        1:25a                        1:60a

     Hungary                                        1:40 | 1:10                       1:20                          –

     Italy                                          1 per class                   1 per class                       –
                                                                                                                         b
                               England              1:20 | 1:20                         –                          1:20
     United Kingdom
                               Wales                1:20 | 1:20                         –                           –c

     Key: – information not retrieved.
     a
       These figures represent ratios for facilities used during breaks; during lessons one toilet/urinal per gender should be
        available on each floor.
     b
       The number of washbasins can be reduced for pupils aged over 11 years.
     c
       For pupils younger than 11 years, washbasins should be in the ratio 1:1 with sanitary fittings; for older pupils washbasins
        should be in the ratio 2:3 with sanitary fittings.
     Sources: Department for Education (2015); Department for Education & Welsh Office (1999); Hungarian Standards
              Institution (2012); Lein (2013); Ministry for Public Works & Ministry for Public Education (1975); Ministry of
              Labour, Social Relations and Solidarity (2015).

12
Policy framework on WASH in schools in the pan-European region_3

Other critical aspects are not sufficiently addressed (see Table 2). Requirements for regular
inspection and maintenance are not specified in the policies of 17 countries; equality is not ensured
by all policies, as 12 countries do not address requirements for facilities used by children with
disabilities; and many countries lack requirements for the provision of hygiene consumables like
soap (14), drying tools (13) and toilet paper (17). Information related to policies ensuring adequate
menstrual hygiene management (MHM) was not retrievable.
Hygiene education is a recognized essential element for empowering children with progressive
acquisition of knowledge and skills to adopt responsible hygiene behaviour for themselves and their
schools. Hygiene education is included in the policies of more than half of the countries in the pan-
European region, but only 19 countries reported that it was integrated into the school curriculum
(see Table 2). Of these countries, not all regulate minimum educational requirements and only 11
include gender-specific aspects, like MHM, in hygiene education.

Legal frameworks are complex and efficient coordination is frequently lacking.

Policies and standards may not always specifically address only schools, and the links between
relevant documents are not always explicit. Depending on the country context, requirements on
WASH in schools can be set by different ministries or departments, including education, health,
labour, construction and/or environment (Table 5).

Table 5. Examples of national standards

Country                                  Legally binding                  Ministry or department setting
                                         requirements in place            requirements
France                                   Partlya                          Labour; education
                                               a
Georgia                                  Partly                           Labour, health and social affairs; education
                                               a
Germany                                  Partly                           Construction; environment

Hungary                                  Yes                              Environment; human resources

Italy                                                                     Labour; education; infrastructure and
                                         Yes
                                                                          transport

Russian Federation                       Yes                              Health
                                               a
                          England        Partly                           Education
United Kingdom
                          Wales          Yes                              Education

a
    Some requirements are legally binding; some are specified in non-statutory guidelines.
Sources: Bauministerkonferenz (2016); Department for Education (2012a; 2012b; 2015); Department for Education &
         Welsh Office (1999); Environmental Protection Agency (2008); Health Officer of the Russian Federation (2008;
         2010); Hungarian Standards Institution (2012); Lein (2013); Ministry for Public Works (1968); Ministry for Public
         Works & Ministry for Public Education (1975); Ministry of Environment (1997); Ministry of Human Resources
         (2012); Ministry of Labour (2008); Ministry of Labour, Social Relations and Solidarity (2015); Ministry of Public
         Education, Youth and Sport (1989); Welsh Government (2012).

Requirements on WASH in schools are frequently scattered across a number of legal documents:
different aspects – such as provisions on sanitation facilities, drinking-water, health surveillance
or hygiene promotion – may sit under different jurisdictions. Some countries, including England,

                                                                                                                             13
Germany and Italy, have therefore developed complementary advisory documents (Department
     for Education, 2015; Lein, 2013; ISPESL, 2005), which provide comprehensive references to
     available legislation and help recipients to understand all their obligations concerning WASH
     (and other issues) in schools. New comprehensive guidelines have also been developed in
     Georgia (Box 1).

        Box 1. New guidelines for WASH in schools in Georgia

        In Georgia hygiene and health in schools are addressed by legislation (Ministry of Labour, Health
        and Social Affairs, 2001; 2007). Further, comprehensive non-statutory guidelines have recently
        been developed (Ministry of Education and Science & Educational and Scientific Infrastructure
        Development Agency, 2013; Ministry of Labour, Health and Social Affairs, 2016). These address all
        main aspects concerning WASH in schools, including schematic representations of how to arrange
        sanitation facilities, shower blocks and sanitation facilities for disabled people adequately in the
        different school categories, as well as requirements for hygiene education and for surveillance of
        WASH facilities. The 2016 guidelines, which are specific to preschools, were officially approved by
        the Ministry of Labour, Health and Social Affairs. Approval of the 2013 guidelines, developed by the
        Ministry of Education and Science and specific to schools, is still pending. To support the guidelines
        with respect to hygiene education, the manual Be clean and healthy was also produced, targeting
        teachers and pupils of elementary schools (Slovinsky & Dalakishvili, 2013).

     The division of roles and responsibilities for different WASH aspects may be spread over
     different institutions, and the leading body that takes overall responsibility often remains
     unclear. A coordination system between all concerned stakeholders should be in place to avoid
     implementation gaps and ensure equal access to WASH for all children. Several countries in
     the pan-European region reported establishment of a coordination body or mechanism to work
     on issues related to WASH in schools (Box 2). Such a mechanism might be regulated within
     national legislation, but it is not always enforced in practice. Other aspects of WASH coordination
     currently in place might affect its efficiency. For example, joint working groups are not always
     permanent; or when a coordinating body is established, in some cases its purpose is limited to
     surveillance only.

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Policy framework on WASH in schools in the pan-European region_3

   Box 2. National coordinating mechanism for WASH in schools

   Of the 20 countries taking part in the WHO meeting on advancing WASH in schools in Bonn,
   Germany, in September 2014, the majority reported that a formal mechanism had been
   established to coordinate the activities of different stakeholders concerned with WASH in
   schools. A number of countries (9) reported that coordination was addressed in national
   legislation; a few (3) reported that a specific body was responsible for coordinating activities. For
   example, in the former Yugoslav Republic of Macedonia, the National Institute of Public Health
   coordinates WASH in schools activities undertaken by different government institutions, while
   the State Sanitary and Health Inspectorate coordinates surveillance activities with the Ministry of
   Education and Science. Several countries reported that intersectoral coordination was triggered
   on an ad hoc basis through implementation of the Protocol or participation in the 2013–2014
   GLAAS reporting cycle.
   Source: Information collected through country briefs from representatives who participated in the meeting.

3.2. Targets for WASH in schools

Targets have been set under the Protocol on Water and Health and reflect country
priorities.

According to the provisions of Article 6 of the Protocol, Parties are required to set national priority
targets on water, sanitation and health. Nine countries have set targets, or are in the process of
setting targets, on WASH in schools, covering five of the 14 target areas (a–n) listed in Article 6,
paragraph 2 of the Protocol (UNECE & WHO Regional Office for Europe, 2006). These include:
• 6.2(a) quality of the drinking-water supplied (3 countries);
• 6.2(b) reduction of the scale of outbreaks and incidents of water-related diseases (4 countries);
• 6.2(c) access to drinking-water (6 countries);
• 6.2(d) access to sanitation (7 countries);
• 6.2(f) application of recognized good practice for implementation (1 country).
Further, one country has set a national target covering improved communication to the public and
education.
Table 6 sets out the variety and nature of the national targets on WASH in schools set by countries
under the provisions of Article 6 of the Protocol. These are sometimes different in scope, as they
are aimed to reflect the current challenges and priorities of each country. Some countries focused
on the initial steps of assessing the condition of WASH in schools and/or estimating the financial
requirements; others planned to act on improving school facilities or hygiene education.

                                                                                                                    15
Table 6. Examples of WASH in schools targets set under the Protocol

     Country           Target areaa    Targets
               b
     Armenia           b, c, d         • Improving access to safe drinking-water in educational facilities (from kindergarten
                                         to senior school and boarding facilities)
                                       • Improving sanitation in educational facilities
                   b
     Azerbaijan        a, b, c, d      • Achieving drinking-water in schools of appropriate quality for main chemical and
                                         microbiological parameters
                                       • Developing a national strategy for prevention and control of soil-transmitted
                                         helminthiasis
                                       • Provision of improved water sources in preschools and schools
                                       • Providing children with access to improved sanitation and conditions for
                                         handwashing with soap in preschools and schools
     Belarus           b               • Reducing the morbidity by acute enteric infections related to the drinking-water in
                                         the educational institutions
     Germany           –               • Improving national communication and education of the general public regarding
                                         drinking-water, with particular consideration of children’s health
     Kyrgyzstanc       b, c, d         • Improving the monitoring of water-related diseases among children
                                       • Assessing the status and required investments for improvement of water supply
                                         systems in schools and preschool institutions and developing a rehabilitation
                                         programme with provision of sustainable funding sources
                                       • Providing improved sanitation facilities for schools and preschool institutions
     Republic of       a, c, d         • Achieving compliance with all existing chemical and microbiological drinking-water
     Moldova                             quality standards in schools
                                       • Increasing access to improved water supply sources for children in schools and
                                         preschool institutions
                                       • Providing access to improved sanitation systems for children in schools and
                                         preschool institutions
     Serbia            c, d, f         • Estimating the investment required to improve water supplies in schools and
                                         preschool facilities from individual wells or connected to rural water supply system
                                       • Estimating the investment required to improve access to sanitary equipment,
                                         proper wastewater disposal and regular emptying of septic tanks in schools and
                                         preschools
                                       • Developing a plan for the improvement of sanitation in schools and preschools
                                       • Improving sanitation in schools and preschools
                                       • Raising awareness among teachers, school staff and pupils of the hygiene of the
                                         sanitation facilities in schools
                                       • Improving WASH surveys in schools by introducing new methodology
                                       • Raising awareness of adequate water supply and sanitation in schools, especially
                                         in those with individual wells
     Ukraine           a, d            • Providing children in preschools and secondary schools with drinking-water of
                                         good quality
                                       • Providing improved sanitation for children in preschools and secondary education
                                         facilities in cities, towns and villages

     a
       The letters represent the target areas listed under Article 6, paragraph 2 of the Protocol.
     b
       The country is in the process of drafting targets, or has drafted national targets that are pending adoption.
     c
       The country has set targets but is not a Party to the Protocol yet.

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Policy framework on WASH in schools in the pan-European region_3

Targets have been set within national programmes to increase access to WASH services,
but hygiene is less prioritized.

The 2014 GLAAS survey (WHO, 2014a) investigated WASH coverage targets for schools
that countries have set or that are required by national policies. The results indicate countries’
commitment to improve accessibility of WASH services in schools in the region (Table 7). This is in
line with the progress observed for policies on WASH in schools outlined in section 3.1.

Table 7. Examples of WASH in schools coverage targets set

Participating country        Sanitation targets          Drinking-water targets        Hygiene promotion targets
                            Coverage       Target year    Coverage     Target year       Coverage      Target year
                                     a
                           target (%)                    target (%)a                    target (%)a
Azerbaijan                           100        2017      Not listed          2017       Not listed         2017
Belarus                              100     Reached            100       Reached              100       Reached
Georgia                               70    Not listed           86       Not listed     Not listed     Not listed
Kazakhstan                            27    Not listed           52       Not listed           100      Not listed
Kyrgyzstan                            90        2020            100           2020       Not listed     Not listed
Lithuania                            100     Reached            100       Reached              100       Reached
Republic of Moldova                  100        2020            100           2020             100          2015
Serbia                               100        2015            100           2015             100          2015
Tajikistan                            80        2015             55           2020       Not listed     Not listed
The former Yugoslav
Republic of                          100    Not listed          100       Not listed     Not listed     Not listed
Macedonia
Ukraine                        20–40       2015; 2020        25–30        Not listed     Not listed     Not listed

a
 Indicator: percentage of schools.
Source: WHO (2014b).

Almost all of the 12 countries in the pan-European region that participated in the 2014 GLAAS
reporting cycle have set coverage targets for water and sanitation in schools (Table 7); however,
fewer than half have set targets for hygiene promotion in schools, which indicates a need to give
this higher priority. Seven countries have set a universal access target for sanitation and/or drinking-
water and/or hygiene in schools. Some of the reporting countries have already reached the coverage
targets set.

3.3. Implementation of policies and targets

The lack of comprehensive implementation plans and funding may impede improvement
of WASH in schools.

Despite numerous policies and programmes, the prevailing conditions of WASH in schools do not
always match national requirements, as shown by the results of the school surveys recently carried
out (see Chapter 4). This divergence indicates that the existence of policies and standards is not

                                                                                                                     17
sufficient to ensure access to safe WASH in schools and it confirms the importance of setting
     targets and strengthening enforcement with funded action plans. As shown in section 3.1, WASH
     in schools requirements are typically addressed in many separate documents. This might be a
     critical hindering factor for implementing concrete activities to ensure compliance in schools.
     According to the data provided in the 2014 GLAAS survey (WHO, 2014b), once policies are approved
     by the government, implementation does not always follow directly. Only a few countries (five of
     the 12 respondents) have progressed further by developing plans for implementation, organizing
     funding and reviewing the policies after implementation (Table 8). Most of the countries reported
     starting to develop a plan to implement WASH facilities in schools only recently. According to the
     2014 GLAAS report (WHO, 2014a), it seems that a strong limiting factor is the amount of available
     governmental budget.

     Table 8. Stages of development and implementation of national policies and plans for WASH in
              schools

     Policies and plans                    Sanitation and drinking-water       Hygiene

     Plan being fully implemented with     Azerbaijan, Belarus, Estonia,       Azerbaijan, Belarus, Estonia,
     necessary funding and regularly       Kazakhstan, the former Yugoslav     Kazakhstan
     reviewed                              Republic of Macedonia

     Plan costed and partially             Republic of Moldova, Serbia,        Republic of Moldova,
     implemented, based on                 Ukraine                             Serbia, Tajikistan, Ukraine
     approved policy

     Implementation plan developed,        Kyrgyzstan, Lithuania, Tajikistan   Kyrgyzstan, Lithuania, the
     based on approved policy                                                  former Yugoslav Republic of
                                                                               Macedonia

     National policy formally approved     Georgia                             –
     and gazetted (formal announcement)

     No national policy or policy still    –                                   Georgia
     under development

     Source: WHO (2014b).

     Table 9 provides examples of specific national or subnational programmes and activities on WASH
     in schools reported by country representatives at the WHO meeting on advancing WASH in schools
     in Bonn, Germany, in September 2014. Many of the programmes target specific geographical
     areas and they are usually aimed to improve a particular aspect of WASH in schools, such as water
     supply and sanitation systems, hygiene education or surveillance, among others.

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